Global health:

HIV/AIDS
September 23, 2016
 Introduction
 HIV (Human Immuno-
deficiency Virus) = Virus that
leads to AIDS.
 HIV damages T or CD4 cells
 HIV uses the machinery of the
CD4 cells to multiply (make
copies of itself) and spread
throughout the body.
 Indicator HIV infection: T or
CD4 cells < 350 cells/mm 3
 Transmission of HIV
 Unprotected sex with someone who has HIV. However:
 Unprotected anal sex is riskier VS unprotected vaginal sex.
 Among men who have sex with other men (gay), unprotected receptive
anal sex is riskier VS unprotected insertive anal sex.
 Unprotected oral sex can also be a risk for HIV transmission, but it is a
much lower risk than anal or vaginal sex.
 Having multiple sex partners or the presence of other sexually
transmitted diseases (STDs)
 Sharing needles, syringes, rinse water, or other equipment used to prepare
illicit drugs for injection.
 Being born to an infected mother—HIV can be passed from mother to
child during pregnancy, birth, or breast-feeding.
HIV is NOT transmitted through
SOCIAL ACTIVITIES
Most at risk group of HIV infections*
1. MSM/Men who have sex with men
2. Women sex workers
3. Transgender women**
** had documentation in their medical records of
substance use, commercial sex work, homelessness,
incarceration, and/or sexual abuse
4. IDUs People in prison.
5. Consider: their clients, children, spouse
• WHO Media centre: People most at risk of HIV are not getting health services they need,
http://www.who.int/mediacentre/news/releases/2014/key-populations-to-hiv/en/ [accessed: Sept, 2014]
• ** HIV among transgender people, http://www.cdc.gov/hiv/group/gender/transgender/ [accessed: February 2016]
 Treatment

 Antiretroviral therapy or ART

 a combination of HIV medicines from at least two
different HIV drug classes (in HIV life cycle) every day 
ART is very effective at preventing HIV from multiplying.
ART also reduces the risk of HIV drug resistance.
 ART can’t cure HIV,
 ART also reduces the risk of sexual transmission of
HIV.
 Treatment: ART
1. ART as prevention:
• reduced risk of transmission virus to their unifected sex
partner by 96%.
2. Pre-exposure prophylaxis (PrEP) for HIV-negative partner
• is the daily use of ARV drugs by HIV-uninfected people to
block the acquisition of HIV.
3. Post-exposure prophylaxis for HIV (PEP): the use of ARV
drugs within 72 hours of exposure to HIV in order to prevent
infection.
• Includes: counselling, first aid care, HIV testing, and
administering of a 28-day course of ARV drugs with follow-
up care.
 HIV prevention (1)
1. Male and female condom use
2. Testing and counselling for HIV and other STIs,
incl. TB
3. Voluntary medical male circumcision:
 reduces the risk of heterosexually acquired HIV
infection in men by approximately 60%.
4. ART use for prevention
5. Elimination of mother-to-child transmission of
HIV (EMTCT)
 HIV prevention (2)
6. Harm reduction for IDUs
 needle and syringe programs;
 opioid substitution therapy for people
dependent on opioids and other evidence
based drug dependence treatment;
 HIV testing and counselling;
 HIV treatment and care;
 access to condoms; and
 management of STIs, TB and viral hepatitis.
Global Epidemic AIDS (2014)
Children with HIV (2014)
Adult HIV prevalence (2013)
AIDS Mortality (2013)
HIV Treatment (Global)
15.8 million people livingwith HIV were
accessing ART as of June 2015.
119 countries reported a total of 95
million people tested in 2010
22 million people who need to be
reached with antiretroviral therapy
 Facilities with HIV testing and
counselling*
The reported number of health
facilities providing HIV testing and
counselling increased to 143,000 in
2011 (129 countries), up from
131,000 in 2010 (119 countries)
Indonesia: 388 health facilities (2011)

* Source: http://www.who.int/gho/hiv/epidemic_response/testing/en/ [Accessed: Feb, 2016]

Source: September 2013 Core epidemiology slides,
http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/201309_epi_core_en.pdf [Accessed: Sept, 2014]
AIDS Epidemic in Indonesia (March 2016)
 MoH RI (Ditjen P2PL), per March 2016:
 Cummulative Cases (1987-2016) of HIV in Indonesia : 191,073 &
77,940 cases of AIDS.
 Among AIDS cases: 42,838 (males) and 24,282 (females); 11,172
(unknown)
 Number of HIV case 1 Jan - 30 March 2016: 32,711
 Number of AIDS case 1 Jan - 30 March 2016: 7,846
 HIV Risk Male:Female = 2:1
 Risk factors of HIV (year 2010-2016):
 67,374 (47.32 %) unsafe heterosex;
 15,570 (10.94%) MSM;
 13,953 (9.8 %) IDUs
 38,165 (26.80%) others (ie. WBP/Warga Binaan Pemasyarakatan
incl. prisoners)
Continue...
 Case Fatality Rate (CFR) AIDS: 0.02% on March 2016.
 Provinces with high number of HIV infection: DKI Jakarta,
East Java, Papua, West Java, and Central Java.
 Provinces with high number of AIDS: East Java, Papua,
DKI Jakarta, Bali, Central Java
Population at-risk of HIV 1987-2016 by age group

117548

25001

9531
4220 5714
1948

≤ 4 yrs 5 – 14 yrs 15 – 19 yrs 20 – 24 yrs 25 – 49 yrs ≥ 50 yrs

HIV cases by Risk Factors in the year
2010 – 2014
Risk factors of AIDS in Indonesia
1987-2014
HIV Control programme in Indonesia in 2013 - 2015
 Voluntary Counseling & Testing/ PITC (VCT) : 990 places.
 Care Support & Treatment (CST)  ART : 284 Reference hospital
and 134 satelite hospital
 Methadone Maintenance Treatment (MMT) : 87 centers
 STIs services: 969 centers
 TB-HIV treatment center: 223 centers.
 PMTCT (Prevention of Mother to Child HIV transmission): 136
centers.
 HIV/AIDS Control in prison (ICE activities, Outreach program,
Peer-group, VCT, Coordination program, MMT, HIV/AIDS referral
program)
 In the mid of 2013, new strategy “Strategic use of ARV (SUFA)”.
Burden
 Psychosocial aspects: Stigma & Discrimination
 Effects: closed status, being afraid to community, low access to
treatment.
 In Soweto, South Africa: informant/caretaker (mother,
grandmother, aunt) refused to open status of HIV to the children
because of stigma, low of knowledge, & skill.
 In Rumania: closed status to children.
 Some of religion goups consider the epidemic of AIDS as a
warning concerning moral message which relates to sex
behaviour, drugs abuse, sins, & illness.
 In Indonesia: HIV & AIDS as a condemnation to modern people.
 Orphan children
Burden
 Economic aspects:
 Increasing both direct & indirect company’s expenses (i.e.
Insurance, medication, abseenteism, low productivity,
increasing expenses for training new staff)
 Lowering family income and increasing family expenses.
 Important sexual Psychosocial Factors
related to Teen Sexual Behaviour
 Knowledge about STD/HIV transmission & method of
protection
 Personal values about adolescents having sex
 Attitudes about condoms and contraception
 Perception of peer norms or family values about sex and
condoms or contraception
 Self-efficacy to refuse unwanted sex or to insist on condom or
contraceptive use
 Skills in communication, decision-making, negotiation, and
refusal.
Source: Kirby, D., Lepore, G., Ryan, J. (2005) Sexual Risk and Protective Factors-- Factors Affecting Teen Sexual Behavior, Pregnancy, Childbearing
And Sexually Transmitted Disease: Which Are Important? Which Can You Change? in McDavid Harrison,K. 2010. Addressing Social Determinants of
HIV/AIDS, Viral hepatitis, STD and TB. On website.[Accessed: Sept, 2014]
 Social & structural interventions that focus
on education, employment and job
security, health services, housing,
income, and social exclusion are needed
to comprehensively address root causes
of HIV vulnerability

Source: CSDH, 2008; Braveman & Gruskin, 2003; Raphael, 2004 in McDavid Harrison,K. 2010. Addressing Social Determinants of HIV/AIDS, Viral
hepatitis, STD and TB. On website.[Accessed: Sept, 2014]
 Global Initiatives
 HIV-AIDS Campaigns through large activities, involving many sectors.
 International organizations (reports, guidelines, policies, campaigns,)
 Social media
 Websites (unaids.org; blogs; aidspace.org; etc)
 Electronic media (TV, Radio, Press,etc)
 Government (Laws, statistics, surveys, HIV hotline, etc)
 Academic, Professionals, etc
 Impacts:
 In the beginning, HIV-AIDS was scared & dangerous  discrimination
 R & D improvement  Increasing global investation : > USD 6,5 billion.
 Treatment & care  Incentives for HR
 Prevention  Social protection & social services
 Program management & administration strenghtening  enabling Environment
 Orphans & vulnerable children  Research
Funding on HIV/AIDS
 In the end of MDGs 2015:
 Since 2000, an estimated US$ 187 billion has been
invested in the AIDS response, US$ 90 billion of
which came from domestic sources.
 USA  more than US$ 59 billion
 GFATM  invests nearly US$ 4 billion each year
towards AIDS programmes and has disbursed more
than US$ 15.7 billion since its creation in 2002.
 Key WHO Partnerships in HIV

UNAIDS

Multilateral Countries
funds
WHO HIV
Programme
foundations Civil society

Bilateral Academic
donors institutions
 HIV/AIDS & UN Sustainable
Development Goals (SDGs)
Sustainable Goal 3: to ensure healthy lives and
promote well-being for all at all ages

 To end the AIDS epidemic by 2030

 By 2020:
 reducing new HIV infections by 75%,
 ensuring 90% of all people living with HIV know their HIV status,
 ensuring 90% of people who know their status have access to
treatment and that 90% of people on treatment have supressed
viral loads, keeping them healthy and reducing the risk of
transmission.
 Challenges in HIV prevention
 CDC reported several challenges in HIV prevention*:
 Too few people with HIV are aware of their infection
 Many people with HIV do not receive ongoing treatment
 Diverse population require tailored prevention approaches
 Disparities in HIV rates are fueled by social and economic
inequities
 Limited resources for HIV prevention force difficult choices.

*Source: Challenges in HIV prevention. CDC. December 2013. In

http://www.cdc.gov/nchhstp/newsroom/docs/HIVFactSheets/Challenges-508.pdf
[Accessed: Sept, 2014]
Challenges in HIV prevention

 Denial to talk about HIV to the public. It is tabboo to talk

about sexuality and sexual behavior which can lead to the
ignorance of HIV transmission.
 Contrasting views of a large number of donors,
duplicating programs.
 Young people (15-24 yrs) are not fully empowered
References
 AIDS info: Education Materials. 2016
https://aidsinfo.nih.gov/education-materials/fact-
sheets/19/73/the-hiv-life-cycle, accessed February
2016.
 Global Health Observatory data. 2016.
http://www.who.int/gho/hiv/en/, accessed: February
2016
 Global HIV/AIDS overview.
https://www.aids.gov/federal-resources/around-the-
world/global-aids-overview/, accessed: February 2016